Healthcare Fraud in America

1. Introduction

It has been observed that the healthcare system in the United States of America (USA) is a target for fraudsters. In 2016, the total cost of healthcare fraud was estimated to be $2.26 trillion. This is expected to rise to $2.625 trillion by 2025. Healthcare fraud includes billing for services that were not rendered, upcoding (billing for a more expensive service than the one that was actually provided), and prescribing unnecessary tests or treatments. It has been estimated that 3-10% of all healthcare expenditure is lost to fraud each year.

Pharmacia & Upjohn Company, a subsidiary of Pfizer Inc., agreed to pay $1 billion in 2009 to settle charges of kickbacks, false claims, and other forms of fraud. In 2013, Pfizer Inc. agreed to pay $2.1 billion to settle criminal charges and civil liabilities arising from kickbacks to health care providers, making a profit without caring about public health, and other unlawful practices.

The problem of healthcare fraud is exacerbated by the fact that the USA has a large number of private insurance companies, each with their own claims processing systems. This makes it difficult to detect and prevent fraud.

2. The cost of healthcare fraud

Healthcare fraud wastes billions of dollars each year which could be used to provide healthcare for the needy or to improve the quality of care for all patients. In addition, it imposes an economic burden on everyone who pays for health insurance, whether through taxes or private insurance premiums.

3. Prevalence of healthcare fraud

Healthcare fraud is prevalent in all parts of the USA. In 2012, the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) published a report on Medicare fraud in 10 states. The report found that there were widespread problems with billing for services that were not rendered, upcoding, and prescribing unnecessary tests or treatments.
In 2013, the OIG published a report on Medicaid fraud in 11 states. The report found that Medicaid Fraud Control Units recovered $4 for every $1 spent on investigations and prosecutions in 2010-2011. The report also found that there were widespread problems with billing for services that were not rendered and prescribing unnecessary tests or treatments.

4. Detecting healthcare fraud

There are various methods of detecting healthcare fraud, including data mining, audits, and tips from whistleblowers. Data mining is a technique that uses computer software to look for patterns in large data sets that may indicate fraudulent activity. Audits are conducted by government agencies or private companies on a random or targeted basis to verify claims submitted for payment. Whistleblowers are employees or former employees who report fraudulent activity to authorities or the media.

5. Strategies for preventing healthcare fraud

There are various strategies for preventing healthcare fraud, including increased regulation, improved data sharing among government agencies, greater use of data mining and analytics, stronger penalties for perpetrators, and better education of consumers and providers about how to avoid fraudulent activity.

6. Conclusion

Fraudulent activities within our current healthcare system are unfortunately all too common as indicated by recent reports revealing such activities in 10 different states across America with an annual cost totaling in the trillions; this needs to change if we want maintain a functional society where people can trust in our ability as a nation to provide quality care without


The main components of a healthcare system are the providers, the patients, and the payers.

Customer service plays a role in healthcare by providing a way for patients to get their questions answered and by providing support during difficult times.

Customer service is important in healthcare because it helps to build trust between the patient and the provider, and it can help to improve health outcomes.

Some ways to improve customer service in healthcare include training staff on how to best communicate with patients, establishing clear policies and procedures, and investing in technology that can help to streamline processes.

Patients can best be served by a healthcare system that is responsive to their needs and that provides them with access to quality care.

Providers face many challenges when it comes to providing excellent customer service within the health care system, including time constraints, limited resources, and bureaucratic red tape.